The anatomy of the infant is designed to breastfeed, to suck. The structure of the mouth and throat are adapted to allow both swallowing and breathing at the same time. There is coordination between the muscles of the mouth, the functioning of the jaw and tongue, and the ability to breathe through the nose which allows for sucking, swallowing and breathing. This should occur in a smooth rhythmic tempo.
Some infants have difficulty with breastfeeding and are unable to effectively feed without pulling off the breast, coughing, choking and preferring one breast. It is not uncommon for infants who have had a traumatic birth or assistance during delivery to have difficulty feeding. Premature infants have the highest risk for feeding difficulties as they may not have developed adequately to master the skills necessary to successfully feed. Some infant have an abnormal head position during delivery which creates excessive forces on protruding parts, like the nose and the jaw. This can be both painful and interfere breastfeeding. Trauma to the nose interferes with ease of breathing through the nose. The infant is an obligate nose breather; the mouth is used for feeding not breathing, so when nose breathing is suboptimal, it can affect feeding. The jaw and the tongue together are used to express milk from the breast. If the jaw is injured, the mouth is usually not straight, it may be more diagonal. When the jaw does not function properly the result is usually inefficient, painful feeding for both the mother and the infant.
Infants that are not initially united with their mothers may have missed a critical window for optimal breastfeeding. With successful breastfeeding the mother produces a hormone, oxytocin. This is an important hormone which is involved with bonding between the mother and infant. Successful breastfeeding allows for optimal nutrition, successful bonding between the mother and baby and training of the structures in the mouth and throat. There are primitive reflexes in place, which help the neonate to find the breast and to suck. Unsuccessful sucking may be an early sign of neurological compromise.
It is important to understand what the problem is so treatment can be directed at the appropriate structures. There is no other specialist who focuses on the mechanical treatment of the infant with sucking dysfunction. If there has been trauma to the nose or the jaw during delivery, this can affect the infants’ ability to effectively suck. The muscles in the tongue and the mouth need to function properly to coordinate the action of sucking and swallowing while breathing. The nerves which supply the tongue, the face, the back of the throat and the neck can be affected with certain procedures during delivery which cause bruising and/or torquing of the cranium. Treatment is gentle with a goal of improving function of the structures involved. The earlier the infant is treated, the easier it is to establish effective feeding. Proper sucking is important not only for successful breastfeeding but for training the muscles of the mouth which later are used in speech and articulation.
During the exam the infant is evaluated to see if they have normal biomechanical functioning. Besides a thorough biomechanical examination, the neck, the cranium and the shoulders are assessed. Injuries to the neck, shoulder or clavicle are common reasons why the infant has pain or discomfort and prefers to feed from one side. These injuries should be evaluated for treatment. It is important that the neck functions properly to avoid plagiocephaly. Plagiocephaly is a flattening of one side of the head, which causes displacement of the ears. This has long term consequences and can be treated with good results. The neck can be gently treated so it regains normal functioning and no longer is a source of pain for the baby. The cranium is inspected for injury and symmetry. Injury to the cranium may be a reason why the infant has a preferred position of the head. It may affect nerves leaving the cranium which supply the face, the tongue, the mouth. This can be treated with gentle maneuvers directed towards restoring normal positioning. The mouth and its’ structures are evaluated next. Some infants have a frenulum or tongue band which attaches too far forward and does not allow them to stretch out the tongue far enough to get a good latch on the breast. Left untreated this can later affect their speech. This can be clipped by a pediatrician during a regular visit. This should be done promptly as it causes a painful latch and inefficient feeding. The tongue is further evaluated to determine if the infant can properly to suck. The infant, who is losing milk while feeding or makes a clicking noise while sucking, may have tongue bunching and can be treated so the tongue functions properly. Next, the shape of the palate has an impact on how efficient they can express milk. Having had a nasogastric tube can affect the palate so that breastfeeding is more difficult. After removal, the infants may continue to make movements with the tongue to expel the tube. This movement is counterproductive to breastfeeding and can be addressed through treatment. Many of the mechanical issues around feeding can be addressed with skilled treatment. Parents can be taught how to work with their child so together with appropriate care there are minimal long term effects.
Tongue-Tie/ Kort Tungband
Ankyloglossia is the medical term which describes the problem with the tongue being anchored to the bottom of the mouth. The tongue can be anchored down in different ways. The frenulum is the thin membrane you see when you lift the tongue. The attachment differs from person to person. The closer to the tip of the tongue it attaches, the less free the tongue is to protrude from the mouth or lift up to the roof of the mouth. This can cause different kinds of problems, most noticeable for the breastfeeding infant. Following the frenulum back to the root of the tongue there is a ligamentous band that can be very thick and short which can also prevent the tongue from free movement. This is referred to as a posterior tongue tie. This band can be felt by sweeping with a finger side to side at the base of the tongue or by pressing on the frenulum back towards the band. A release of the frenulum will not free up this part of the tongue. Intervention would need to address the thickened band which is at the base or root of the tongue.
There are lip ties/ kort läppband as well which can interfere with a proper latch during breast feeding. There are some infants that require a release so they are able to feed properly. Ligaments do not grow back so if it is properly and completely released, further treatment would be to address the tongue itself.
There are buccal ties as well which are bands inside the mouth in the upper and lower jaws between the outside of the upper jaw and the muscles of the cheeks and inside the bottom jaw attaching to the inside of base of the lips. These need to be evaluated as well to determine if they are a problem for eventual treatment.
Intervention is geared to release the part of the frenulum or ligaments tying down the lips or tongue. Besides laser or cutting, there are techniques which can be done by chiropractors with special skills in treating infants. These are geared to treat the tongue, which is a muscle, so that it can move properly in the mouth. Treatment addresses the tongue both inside the mouth and outside the mouth under the chin. The ligamentous band can also be stretched during treatment, as well as the lips ties.
An important point in this discussion is that not all babies with feeding issues have a tongue tie. The chiropractor skilled in this area can assess if there are tongue or lip ties. They have the skills to determine if the problem is caused by other mechanical issues. Infants with torticollis or plagiocephaly have difficulty lying comfortably at the breast and commonly have feeding issues. Some infants that have had uneven pressure on the face and jaw inutero or during delivery can have difficulty with breastfeeding. A thorough assessment includes evaluation of the mouth, tongue and lips and then the jaw, the neck and the cranium. During an examination these mechanical issues are assessed to determine the different problems the infant has. These skills in mechanical assessment of the infant are specific to the chiropractor specializing in infant care.
Dr. Weber has advanced skills in assessing infants for mechanical problems. Treatment is gentle and parents receive exercises to do with the infant at home.
Chiropractic care for infants with difficulty breastfeeding
A recent article took up chiropractic care for infants, particularly in regard to tongue tie. As a chiropractor specialized in the care of infants and children, I would like to make some comments. First, the practitioner caring for infants is recommended to have further education in the area of pediatrics to ensure safe care for this population. There are only a few in Sweden that have this competency. We assess infants and children for mechanical problems which interfere with normal function. This includes problems with breastfeeding, which includes tongue tie. The techniques we use are modified for age and development. A research project in the UK included over 2000 mothers. Results were published in 2019 in a peer reviewed journal JMPT: “Maternal Report of Outcomes of Chiropractic Care for Infants”. Statistically significant improvements were reported across all aspects of infant behavior studied, including feeding problems, sleep issues, excessive crying, problems with supine sleep position, infant pain, restricted cervical range of motion, and time performing prone positioning. Maternal ratings of depression, anxiety, and satisfaction with observed by mothers were positive and may be clinically relevant.” Chiropractors with advanced education in this area offer an alternative care addressing the mechanical functioning, which is safe and parents are very satisfied with.
Tongue-Tie/ Kort Tungband
Ankyloglossia is the medical term which describes the problem with the tongue being anchored to the bottom of the mouth. The tongue can be anchored down in different ways. The frenulum is the thin membrane you see when you lift the tongue. The attachment differs from person to person. The closer to the tip of the tongue it attaches, the less free the tongue is to protrude from the mouth or lift up to the roof of the mouth. This can cause different kinds of problems, most noticeable for the breastfeeding infant. Following the frenulum back to the root of the tongue there is a ligamentous band that can be very thick and short which can also prevent the tongue from free movement. This is referred to as a posterior tongue tie. This band can be felt by sweeping with a finger side to side at the base of the tongue or by pressing on the frenulum back towards the band. A release of the frenulum will not free up this part of the tongue. Intervention would need to address the thickened band which is at the base or root of the tongue.
There are lip ties/ kort läppband as well which can interfere with a proper latch during breast feeding. There are some infants that require a release so they are able to feed properly. Ligaments do not grow back so if it is properly and completely released, further treatment would be to address the tongue itself.
There are buccal ties as well which are bands inside the mouth in the upper and lower jaws between the outside of the upper jaw and the muscles of the cheeks and inside the bottom jaw attaching to the inside of base of the lips. These need to be evaluated as well to determine if they are a problem for eventual treatment.
Intervention is geared to release the part of the frenulum or ligaments tying down the lips or tongue. Besides laser or cutting, there are techniques which can be done by chiropractors with special skills in treating infants. These are geared to treat the tongue, which is a muscle, so that it can move properly in the mouth. Treatment addresses the tongue both inside the mouth and outside the mouth under the chin. The ligamentous band can also be stretched during treatment, as well as the lips ties.
An important point in this discussion is that not all babies with feeding issues have a tongue tie. The chiropractor skilled in this area can assess if there are tongue or lip ties. They have the skills to determine if the problem is caused by other mechanical issues. Infants with torticollis or plagiocephaly have difficulty lying comfortably at the breast and commonly have feeding issues. Some infants that have had uneven pressure on the face and jaw inutero or during delivery can have difficulty with breastfeeding. A thorough assessment includes evaluation of the mouth, tongue and lips and then the jaw, the neck and the cranium. During an examination these mechanical issues are assessed to determine the different problems the infant has. These skills in mechanical assessment of the infant are specific to the chiropractor specializing in infant care.
Dr. Weber has advanced skills in assessing infants for mechanical problems. Treatment is gentle and parents receive exercises to do with the infant at home.
Support for the Breastfeeding Baby: The Chiropractor’s Role
Joyce Miller, BSc, DC, PhD
Associate Professor, Anglo-European College of Chiropractic Clinic (AECC); Bournemouth BH5 2DF
Little is more important to the long-term health of the newborn baby than breastfeeding. All health care professionals must use their individual skills to assist the mother and baby to achieve a successful breastfeeding dyad.
Mechanical forces during intra-uterine life and during birth may negatively affect the oral-motor function of the newborn. Although it is difficult (if not impossible) to precisely establish exact reasons for these problems, assisted births such as forceps, vacuum extraction and cesarean sections have been implicated.
It is the job of the chiropractor, who provides manual therapy for structural problems in the human skeleton, to detect these physical problems and to work to maximize their functional effectiveness. An examination of the infant must be performed to detect any musculoskeletal problems that may affect the infant’s feeding efficiency. A common example is an injury to the sterno-cleido-mastoid muscle either due to restricted intra-uterine position or to minor injury during birth. This may result in a head tilt seen in the child as well as reticence to feed on the “uncomfortable” side.
The chiropractor is one of the many professionals ready to support and assist the breast feeding dyad toward success so that the child may continue to feed in the long term. In a recent study of infants referred to chiropractic clinic for treatment of sub-optimal breastfeeding, most children improved and were able to go on to exclusive breastfeeding. The role of chiropractic care is to examine for and treat biomechanical problems implicated in suboptimal breastfeeding.
Chiropractic care of infants is gentle and well accepted by both infant and parents. It has been shown to have high satisfaction rates by parents.
References:
Opiyo N, English M. 2011. What clinical signs best identify severe illness in young infants 0-59 days in developing countries ADC;96:1052-1059.
Hall A. 2002. Breastfeeding assessment score to evaluate the risk for cessation of breastfeeding by 7-10 days. J ped;241:659-64.
Evans S. 2003. Effect of cesarian section on breast milk transfer to the normal term newborn over the first week of life. Arch Dis Child Fetal Neonat;141:659-64.
Griffiths T. 2004. Do tongue-ties affect breastfeeding? J Hum Lact;20(4):409-14.
Miller-Loncar C, Bigsby R, High P, Wallach M, Lester B. 2013. Infant colic and feeding difficulties. Arch Dis Child 2004;89:908–912. doi: 10.1136/adc.2003.033233.
Geddes DT, Sakalidis VS, Hepworth AR, McClellan HL, Kent JC, Lai CT, Hartmann PE. 2012. Tongue movement and intra-oral vacuum of term infants during breastfeeding and feeding from an experimental teat that released milk under vacuum only. Early Hum Dev;88(6):443-9. doi: 10.1016/j.earlhumdev.2011.10.012. Epub 2011 Nov 26.